Applied Environmental Statistics

Texas A&M University • AGLS Building Room 120 • College Station

Registration Form

(Please type or print) – Complete for Participant List

First Name: Last Name:

Title: Agency/Organization:

Address:

City: State: Zip:

Phone: Fax: Email:

Any special needs (dietary or other):


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Registration fee includes: electronic course materials and a certificate of completion.
Please note: to be eligible for this discounted rate, please use non-federal funds for course registration if available.

______Registration before 7/21 @ $400.00 $______

______-Late Registration (After 7/21) @ $500.00 $______

______Printed version of Manual @ $15.00 $______

______Parking ($20/week) @ $20.00 $______

Total Fees Submitted $______

PAY BY:

 Purchase Order (government/state only) If paying by purchase order, please fax or email your registration form to Texas Water Resources Institute and submit copy to your bookkeeper for payment processing.

 Check - payable to Texas Water Resources Institute, Account 06-215071-89531

 Credit Card – MasterCard, Visa or American Express accepted
Mail or fax completed credit card authorization form (see below)

Send payment to:

Texas Water Resources Institute Questions may be directed to:

ATTN: Applied Environmental Statistics Nikki Dictson

1500 Research Pkwy., Suite A110 Phone: (979) 458-5915

College Station, TX 77843-2118 Fax: (979) 845-0662

E-mail:

Tax I.D. 74-6000541

This registration form serves as an invoice. Separate invoices will not be mailed. There will be no refunds for cancellations. Substitutions are allowed, providing that notification is sent to Nikki Dictson () in advance.

Texas A&M AgriLife Extension Service

Credit Card Authorization Form

Please print or type:

Date: ______

Name (as it appears on card): ______

(Please print)

Registrant’s Name(s) (if different from above): ______(Please print)

Billing Address for Credit Card: ______

Description of Purchase: Registration for Applied Envirnomental Statistics Training
Texas A&M University, College Station, Texas

Amount: $______

_____MasterCard _____Visa _____American Express

(Please check type of credit card above)

Credit Card Number: 3 digit security code from back of card:

Expiration Date: ______

Signature: ______

Telephone Number: ______